Constipation in Adults

Constipation in Adults

Disclaimer

Contents

Disclaimer ............................................................................................................................................................................................ 1

Background .................................................................................................................................................. 2

About constipation .......................................................................................................................................................................... 2

Assessment ................................................................................................................................................... 2

Medications ........................................................................................................................................................................................ 2

Constipation factors in aged care .............................................................................................................................................. 2

Secondary causes ............................................................................................................................................................................. 2

Neurological disorders ................................................................................................................................................................... 3

Management ................................................................................................................................................ 3

Concerning clinical features ......................................................................................................................................................... 4

Simple measures............................................................................................................................................................................... 4

Bulk-forming laxatives .................................................................................................................................................................... 4

Osmotic laxatives.............................................................................................................................................................................. 4

Stimulant laxatives ........................................................................................................................................................................... 5

Stool softening agents ................................................................................................................................................................... 5

Rectal therapies................................................................................................................................................................................. 5

Role of physiotherapy in managing anorectal disorders .................................................................................................. 5

Referral ......................................................................................................................................................... 6

Information .................................................................................................................................................. 6

For health professionals................................................................................................................................................................. 6

For patients ......................................................................................................................................................................................... 6

South Eastern Melbourne PHN Constipation in Adults pathway

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Background

About constipation

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Constipation is a reduced frequency or ease of stool passage. There maybe sensation of incomplete

evacuation, bloating, and straining.

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Constipation is the difficult passage of small, hard stools.

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Constipation is common, with a prevalence of 15 to 20% in the general population.

Assessment

1. Take a history of frequency and consistency of bowel actions ¨C the Bristol stool chart can be

useful. Ask about:

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medications.

Medications

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Many medications affect bowel habits. Consider:

? antacids.

? anticholinergics.

? antidepressants and antipsychotics.

? calcium channel blockers.

? iron and calcium supplements.

? NSAIDs.

? analgesics.

recent changes in bowel habit, soiling, perianal pain, rectal bleeding, abdominal pains.

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dietary changes.

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unintentional weight loss.

2. Ask about family history e.g., bowel, ovarian or breast cancer, inflammatory bowel disease (IBD),

coeliac disease.

3. Ask about constipation factors in aged care.

Constipation factors in aged care

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Diet ¨C decreased fibre in softened food, or decreased intake

Activity ¨C decreased or bed bound

Ability to self toilet

Medications contributing to constipation

Constipation contributing to challenging behaviour in dementia

4. Perform examination:

? Check weight and vitals.

? Perform abdominal examination.

? Perform rectal examination if recent onset.

5. Consider secondary causes and arrange investigations:

Secondary causes

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Anorectal disorders

South Eastern Melbourne PHN Constipation in Adults pathway

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Carcinoma

Fissures

Haemorrhoids

Worms

Crohn's disease

Irritable bowel syndrome (IBS)

Coeliac disease

Connective tissue disorders

Depression

Dietary

Eating disorder e.g., anorexia nervosa, bulimia

Metabolic disorders

Metabolic disorders

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Diabetes

Hypothyroidism

Pregnancy

Hypopituitarism

Hypercalcaemia

Hyperkalaemia

Neurological disorders

Neurological disorders

? Cerebrovascular accident (CVA)

? Autonomic neuropathy

? Spinal lesion

? Multiple sclerosis

? Parkinson's disease

? Hirschsprung's disease

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Poisons e.g., lead

Disrupted circadian rhythm e.g., shift work or travel

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Blood tests including electrolytes, calcium, thyroid function tests, FBE, iron studies, coeliac

serology

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Faecal occult blood test (FOBT)

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Avoid unnecessary abdominal X-ray which is not indicated for diagnosis of constipation.

Management

1. Arrange immediate gastroenterology referral or admission if:

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suspected large bowel obstruction.

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faecal impaction that has not responded to adequate medical management.

2. If concerning clinical features, arrange urgent or routine gastroenterology referral. If aged care,

consider patient wishes and advance care plan or directive prior to referral.

South Eastern Melbourne PHN Constipation in Adults pathway

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Concerning clinical features

Constipation in patients aged > 40 years, with a duration of more than 6 weeks but

less than 12 months, with one or more of the following:

Rectal bleeding or positive faecal occult blood test

Weight loss (¡Ý 5% of body weight in previous 6 months)

Abdominal or rectal mass

Patient or family history of bowel cancer (first-degree relative aged < 55

years)

? Iron deficiency that persists despite correction of causative factors

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3. If functional idiopathic constipation:

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advise the patient on simple measures that can help relieve idiopathic constipation, and

prevent recurrence. Provide patient handout.

Simple measures

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Maintain adequate dietary fibre and fluid intake.

Respond rapidly to urge to defecate.

Exercise regularly.

commence medications if resistant or severe constipation:

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Bulk-forming laxatives

Bulk-forming laxatives

? Increase faecal mass, which stimulates peristalsis.

? Full effect may take some days to develop.

? Valuable in patients with small hard stools, if increase in dietary fibre is

not sufficient to relieve constipation.

? Adequate fluid intake must be maintained.

? Common side-effects include flatulence and abdominal distension.

? Common preparations include:

o psyllium e.g., Metamucil, Benefibre, psyllium husks from health

food stores.

o sterculia e.g., Normacol, Normacol Plus (also has stimulant

action).

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Osmotic laxatives

Osmotic laxatives

? Increase the amount of water in large bowel.

? Avoid in intestinal obstruction.

? Common preparations include:

o oral lactulose ¨C adults ¨C 15 to 30 mL daily until response, then

10 to 20 mL daily.

o rectal sodium citrate (microlax or micolette).

o second-line option ¨C macrogols e.g., Movicol, Lax-sachets,

funded for certain conditions. Adults ¨C 1 sachet or scoop a day.

Maximum dose is 3 sachets or scoops per day.

o magnesium sulphate (Epsom salts):

? 15 g in 240 mL water. Maximum dose is twice a day.

South Eastern Melbourne PHN Constipation in Adults pathway

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Use with caution in renal and cardiovascular disease,

and the elderly.

Stimulant laxatives

Stimulant laxatives

Increase intestinal motility and often cause abdominal cramps.

Avoid in intestinal obstruction and inflammatory bowel disease.

Not suitable for long-term use due to stimulants causing atonic bowel.

Common preparations include:

o bisacodyl e.g., Lax-tabs, Dulcolax, Fleet

o sennoside e.g., Laxsol, Coloxyl and senna, Senokot

o glycerol suppositories.

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Stool-softening agents

Stool softening agents

? Docusate sodium e.g., Coloxyl probably acts as both a stimulant and a

softening agent.

? Combination products with additional stimulants (e.g., Coloxyl with

Senna) often cause abdominal cramps.

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Rectal therapies

Rectal therapies

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Osmotic, lubricating, and stimulating agents can also be

administered per rectum. Common preparations include Microlax,

Glycerol, Bisalax.

Water enema therapies may also improve rectal emptying.

Manual evacuation sometimes necessary.

4. If pregnant, and dietary and lifestyle changes fail to control constipation:

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try a bulk-forming laxative first.

consider also an osmotic laxative.

if a stimulant effect is necessary, consider bisacodyl or senna.

5. If chronic constipation, consider GP care plan and team care arrangement with referrals to

appropriate allied health clinicians for assistance in management of symptoms.

Role of physiotherapy in managing anorectal disorders

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Patient education ¨C intestinal health and routine, toileting, diet

Exercise ¨C pelvic and abdominal musculature

Pain management

Manual techniques

Biofeedback techniques

South Eastern Melbourne PHN Constipation in Adults pathway

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